General Anesthesia Division

... begins between 06:30 and 06:45. As in most rotations, residents are expected to perform pre-operative evaluations on any “in-house” patients as well as review the Pre-Operative Services visit from patients undergoing same day or ambulatory surgery. Unique to the G-rotation is a dedicated open block time in the operating room for the general surgeons. This time is often filled by appendectomies and cholecystectomies, but essentially involves any patient that presents to the Emergency Department in need of surgery. Cases such as intestinal ischemia, incarcerated hernias, obstructing GI cancers are all commonplace. Though this may lack the formal structure of some other rotations, it is always viewed as an adventure. To paraphrase Forrest Gump “Life is like a box of chocolates… You never know what you are going to get…” These on-the-fly cases provide some of the best teaching opportunities as everyone must find the appropriate balance of surgical urgency and pre-operative evaluation. Patients may present with little more than their list of medications and some detective work is needed to find out why they are on a certain medications or to try and figure out how severe their heart disease really is. Sometimes discussions on anesthetic management and plan can only be made in the Pre-op area after talking to the patient. The diverse patient population, from young and healthy to those presenting with multi-organ system failure, makes this one of the more challenging rotations for junior residents that are still learning the ropes.

... involves more complex patients and cases. This rotation is typically for second and third year residents. Many of the cases are with the Surgical Oncology division and include pancreaticoduodenectomy (Whipple) procedures, esophageal/gastric resections and major liver resections. Invasive monitoring, large fluid shifts and longer duration surgeries are considered the norm for many of these cases. Discussion topics for these cases are centered around intra-operative fluid resuscitation, assessment of volume status, physiologic monitoring and Massive Transfusion. Due to the invasive nature of these procedures, regional anesthesia is common. Some patients have epidurals that were placed by the pain service, and for others, rectus sheath catheters or Transverse Abdominal Plane (TAP) blocks are placed by the intra-operative team at the end of surgery.

... entails a pre-op evaluation that becomes the usual alphabet soup of chronic medical problems: CAD S/P CABG with PCI, AICD, PPM, COPD, DM, AAA, CEA, CRI, PVD etc etc. As the surgical procedures are diverse, so are the anesthetic techniques. General, regional and sedation cases are all common place depending upon the procedure. Carotid Endarterectomies are performed both awake and asleep, typically based on surgical preferences. In fact one of the hardest decisions you may have during this rotation is whether to use the pig, chicken or monkey squeaky toy to assess your patient's neurological status with Carotid clamping. Endovascular abdominal aortic stents are commonplace with a growing number of juxta-renal fenestrated stents being done. Dedicated hybrid Operating Rooms for combined fluoroscopic and open procedures are due to open later this year. Thoracic aortic stents are done for both vascular disease and for traumatic injury. Instead of being placed accidentally during epidural placement, residents will learn to place lumbar sub arachnoid on purpose for drainage of cerebral spinal fluid for spinal cord protection during low thoracic stents. Despite the move to minimally invasive surgical procedures, a number of abdominal aortic aneursyms are still done as primary open procedures. Residents will experience the complex physiology of aortic cross clamping and a major laparotomy all rolled into one day long procedure.

... is most likely a night in the life of a Resident. Though not a dedicated rotation, trauma cases become one of the mainstays of any call night during the summer at Stony Brook. Stony Brook Medicine has recently undergone its site verification and approval as an American College of Surgeons Level 1 Trauma Center. On average, we have between 1200 to 1400 trauma cases per year and the number continually rises. The local communities are not part of the “knife and gun club”, much to the pleasure of the faculty, residents and staff that live in them. However, as the Level One trauma center, a growing volume of penetrating trauma is being seen that is airlifted from other areas on Long Island. Regardless, blunt trauma associated with motor vehicle accidents constitutes the majority of our major trauma cases. These present numerous anesthetic challenges from intra-abdominal solid organ injury and massive transfusion to closed head traumatic brain injury. Stony Brook Medicine has a Massive Transfusion Protocol that with one step gives essentially unlimited access to over 100 units of blood products should you need it.

... is spent at the Pre-Operative Services clinic, a standalone outpatient clinic about 10 minutes from the hospital, conveniently located near a Starbucks, sushi restaurant, and Ralph’s Italian ices. Reset your alarm clocks as your typical day will begin between 8-9am. You will work closely with the medical director of Pre-Operative Services, Dr. Meng Wang. Along with a rotating group of other attendings, you will have the guidance necessary to make the sometimes challenging decisions regarding preoperative evaluation for patients undergoing elective or scheduled surgery.

As an anesthesiology consultant, you will see patients who are ASA Physical Status Class III or IV, ASA II patients with specific perioperative issues, or ASA I patients with questions regarding anesthesia. The experience provides a bird’s eye view of several perioperative issues. For example, you may have a patient with coronary artery disease status post recent coronary stenting with drug-eluting stents presenting for elective surgery, for whom there are specific guidelines. You will also have a patient with end-stage renal disease on hemodialysis who presents for elective surgery, for whom logistical coordination is required to prevent day-of-surgery hyperkalemia or hypovolemia. Several issues will require further reading, consultation of other medical practitioners, and conversation with the patient's surgeon.

You will have the opportunity to work closely with the various clinic staff in a collegial environment-- PAs, NPs, nurses, and clinical associates. Some of these Licensed Independent Practitioners (LIPs) are very knowledgeable about anesthesiology and potential perioperative problems. In some situations, however, your clinical expertise gathered over CA-1 year will be invaluable in the guiding the care of complicated patients.

In a simple sense, you will have been “pre-opping” patients before. At times you may have thought, “I wish I had the echocardiogram report or a prior EKG.” At Pre-Operative Services, you will be able to obtain prior records, which may change overall management. You can anticipate problems for your colleagues who will eventually do the case!

As it is a clinic, appointments wind down by 5pm, and you will have the evening to study on the topics of the day.
- contributed by Richard Thalappillil, CA-3